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• <br /> •!' - , V - <br /> • <br /> MARION COUNTY PiatLIC WORDS <br /> •e ''°',., - BUILDING INSPECTION DIVISION • . <br /> • `„ _!_� 5155 Silverton Rd NE <br /> • _== = ,=-_= Salem OR 97305 • <br /> • ---- -' - (503) 588-5147 FAX(503) 588-7948 <br /> - http://pnblicworks.co.marion.or.us/buil.ding/ • <br /> • • • = • SEPTIC TANK ABANDONMENT FORM • . <br /> - THE SEPTIC TANK AT: • - <br /> S r - <br /> • <br /> . - • ; ACTIVTTYNUMBER • <br /> WAS PUMPED BY: • . <br /> - .DEQ License#- - • • - ••. <br /> DATE TANK PUMPED: • . • <br /> r . <br /> • •INCLOSE A COPY OF'1'HL PITAA/IPING RECEIPT WITS THIS FORM. • • <br /> THE TA1 WAS: <br /> •• • • [1- - REMOVED . . - . • - <br /> • [1 FILLED - - . - <br /> (NO11'J: The bottom of the tank should be perforated or cracked to prohibit the <br /> - •- • accumulation of surface water in the tank) • <br /> FILL MATERIAL: - •• • •• - • - • - <br /> • . •[] , RE.ECT.SAND . • • • • - <br /> • <br /> []- -BAR RUN GRAVEL - • <br /> [] . CRUSHED ROCK - <br /> • <br /> COMPANY NAME: - . - - - <br /> SIGNED: •DATE:_ • • • <br /> MC s-az - • <br /> rev:6/03 • • <br />